Emily J. Campbell

Interval Colorectal Cancer After Colonoscopy

BACKGROUND As more patients are screened for colorectal cancer a small but significant number of interval cancers develop after colonoscopy for colorectal cancer screening. MATERIALS AND METHODS We reviewed records of 75,314 adult patients who underwent colonoscopy for screening or diagnostic purposes between 1998 and 2006 inclusively, and identified 77 who developed interval cancers within the next 5 years. We reviewed their original endoscopic findings to determine the clinical and endoscopic factors that might predict a greater risk for future cancers. RESULTS Patients aged ≥ 60 years had a higher risk of an interval neoplasm (P < .0001). Interval cancers were more common on the right side of the colon and in the hepatic flexure (both P < .0001). We did not observe an increased rate of interval cancers in patients with poor preparation (P = .799); however, examination completion rates did affect the rate of interval cancers (P = .016). CONCLUSION Better identification of higher risk patients and assurance of follow-up examinations might increase the percentage of colon cancers discovered at an early stage. Special attention to careful examination of the right colon is key.

The safety of nurse-administered procedural sedation compared to anesthesia care in a historical cohort of advanced endoscopy patients.

BACKGROUND:In April 2010, in response to a change in Centers for Medicare and Medicaid Services regulation placing deep sedation under hospital anesthesia services, our institution began providing anesthesia care for all advanced endoscopic procedures. Because it remains unknown whether anesthesia care reduces sedation-related complications or improves quality of care versus nurse-administered sedation for endoscopic retrograde cholangiopancreatography and endoscopic ultrasound patients, we retrospectively compared complications in a 5-year historical cohort before and after the policy change. METHODS:We reviewed a historical cohort of 9598 consecutive endoscopic retrograde cholangiopancreatography and endoscopic ultrasound examinations for adult patients at a single institution during a 5-year period (October 2007–October 2012). We compared procedures performed before and after the policy change for the incidence of sedation, endoscopic, and total complications, and for major morbidity and mortality. RESULTS:The incidence of reported sedation-related complications was 0.38% (17 of 4514) before the policy change and 0.08% (4 of 5084) after the policy change, which was statistically significant (P = 0.002, diff = 0.3, 95% confidence interval, 0.11%–0.53%). Endoscopic complications were not significantly different before versus after: 0.66% vs 0.87% (P = 0.293, diff = 0.2, 95% confidence interval, −0.16% to 0.56%). Total complications (1.11% vs 1.00%, P = 0.618) and major morbidity and mortality (0.27% vs 0.33%, P = 0.581) did not differ between the 2 time periods. CONCLUSIONS:Anesthesia care for advanced endoscopy in a high-risk population significantly reduced sedation complications compared with nurse-administered sedation. Endoscopic complications were unchanged. The sedation risk reduction did not reduce major morbidity, mortality, or total complications.

Hospital readmissions in decompensated cirrhotics: Factors pointing toward a prevention strategy

AIM To reduce readmissions and improve patient outcomes in cirrhotic patients through better understanding of readmission predictors. METHODS We performed a single-center retrospective study of patients admitted with decompensated cirrhosis from January 1, 2011 to December 31, 2013 (n = 222). Primary outcomes were time to first readmission and 30-d readmission rate due to complications of cirrhosis. Clinical and demographic data were collected to help describe predictors of readmission, along with care coordination measures such as post-discharge status and outpatient follow-up. Univariate and multivariate analyses were performed to describe variables associated with readmission. RESULTS One hundred thirty-two patients (59.4%) were readmitted at least once during the study period. Median time to first and second readmissions were 54 and 93 d, respectively. Thirty and 90-d readmission rates were 20.7 and 30.1 percent, respectively. Predictors of 30-d readmission included education level, hepatic encephalopathy at index, ALT more than upper normal limit and Medicare coverage. There were no statistically significant differences in readmission rates when stratified by discharge disposition, outpatient follow-up provider or time to first outpatient visit. CONCLUSION Readmissions are challenging aspect of care for cirrhotic patients and risk continues beyond 30 d. More initiatives are needed to develop enhanced, longitudinal post-discharge systems.

Adverse Event and Complication Management in Gastrointestinal Endoscopy

Gastrointestinal endoscopy is a remarkably safe set of diagnostic and therapeutic techniques, and yet a small number of significant complications and adverse events are expected. Serious complications may have a material effect on the patient’s health and well-being. They need to be anticipated and prevented if possible and managed effectively when identified. When complications occur they need to be discussed frankly with patients and their families. Informed consent, prevention, early detection, reporting, and systems improvement are critical aspects of effective complication management. Optimal complication management may improve patient satisfaction and outcome, as well as preserving the reputation and confidence of the endoscopist, and may minimize litigation.

Performance Improvement: Quality Is in the Cards

Improving the quality of care is an unceasing goal of clinical practice, achieved with a variety of methods. Analyzing one such method, Drs. Inra, Nayor, and colleagues contributed a study, ‘‘Comparison of colonoscopy quality measure across various practice settings and the impact of performance scorecards’’ to this issue of Digestive Diseases and Sciences [1], in which they compare physician performance before and after the distribution of individual scorecards for colonoscopic withdrawal times, cecal intubation rates, and adenoma detection rates (ADR) for endoscopists practicing in a tertiary-care hospital, a community-based private hospital, and a private practice group. They reported that, on average, the endoscopists in each practice venue performed high-quality screening examinations at baseline with no statistically significant improvements in performance after the distribution and review of the scorecards. Although the results of this study were negative, the authors’ careful analysis of an important and common process is informative and begins to fill a gap in the literature regarding endoscopy quality measurement. Feedback and scorecards for improvement may not be apparently effective when the baseline performance is already quite favorable, as it is reported here. One can imagine a skilled endoscopist looking at his or her report and concluding that they perform rather well and no change or improvement is needed [2]. In contrast, one might expect that if there had been a significant unfavorable outlier, the endoscopist in question would have been alerted and motivated for a modification in his or her practice, particularly when compared with their peers, as the authors also noted. This same study might have been repeated in a group of less experienced or lower-volume endoscopists with a very different outcome. A study to show meaningful performance improvement would likely need a significant number of outliers. As suggested by the authors, there is experience to suggest that the simple knowledge that performance metrics are being monitored is motivating. In our own tertiary-care hospital, we have been providing scorecards to physicians for 10 years, with individual results compared to the practice and national standards. The year we announced the addition of ADR to our report, the overall rates increased by almost 10%. Sometimes the information in the scorecard is sufficient to promote change, especially if the goals have face validity and are achievable [3]. Reports commonly begin confidentially in order to transmit information in a nonthreatening fashion, but may be more effective if delivered regularly by a trusted colleague and as part of an overarching quality improvement structure. When an outlier needs to be alerted of their performance, mentoring or instruction in a skill that may be lacking should accompany the information. This second level of feedback for performance improvement is being adopted in most training programs. Concurrent specific feedback and instruction using simulation or video recording seems particularly effective [4, 5]. Moreover, the medical profession needs to learn how to use these data in order to most effectively promote active learning throughout one’s career. The selection of the metrics is a key factor [6]. The performance metrics selected by the authors were standard well-established criteria for screening colonoscopy quality [7]. Since they are well understood, it is likely that the participating endoscopists were not naive to the criteria or their general performance. A greater impact might have & James M. Richter jrichter@mgh.harvard.edu